In this episode of the ShiftShapers podcast, we explore the complex world of Pharmacy Benefit Managers (PBMs) and their impact on healthcare costs, sparked by the Johnson & Johnson lawsuit. Our guest, USRxCare President Renzo Luzzatti, with a 30-year healthcare background, discusses the Consolidated Appropriations Act of 2021, which is aimed at shifting power back to payers from vendors by enhancing transparency and fiduciary responsibilities. The episode sheds light on the lawsuit against J&J for excessive pharmaceutical payments through their PBM, Express Scripts, highlighting the issue of overpayment in the industry. Luzzatti emphasizes the necessity of fiduciary PBMs, devoid of conflicts of interest, and the importance of transparency and beneficiary interests. We also discuss how employers can strategically manage their pharmacy benefits to avoid overpayment and ensure compliance with fiduciary duties, emphasizing the role of advisers in navigating this complex territory. The conversation also touches on current trends and future outlooks for managing pharmacy benefits more effectively and ethically. Each of these insights are critical to business owners and other organizational leaders who must manage healthcare benefits to be cost-effective while providing for employee health needs.
USRxCare: https://usrxcare.com/
In this episode of the ShiftShapers podcast, we explore the complex world of Pharmacy Benefit Managers (PBMs) and their impact on healthcare costs, sparked by the Johnson & Johnson lawsuit. Our guest, USRxCare President Renzo Luzzatti, with a 30-year healthcare background, discusses the Consolidated Appropriations Act of 2021, which is aimed at shifting power back to payers from vendors by enhancing transparency and fiduciary responsibilities. The episode sheds light on the lawsuit against J&J for excessive pharmaceutical payments through their PBM, Express Scripts, highlighting the issue of overpayment in the industry. Luzzatti emphasizes the necessity of fiduciary PBMs, devoid of conflicts of interest, and the importance of transparency and beneficiary interests. We also discuss how employers can strategically manage their pharmacy benefits to avoid overpayment and ensure compliance with fiduciary duties, emphasizing the role of advisers in navigating this complex territory. The conversation also touches on current trends and future outlooks for managing pharmacy benefits more effectively and ethically. Each of these insights are critical to business owners and other organizational leaders who must manage healthcare benefits to be cost-effective while providing for employee health needs.
USRxCare: https://usrxcare.com/
The recent Johnson Johnson suit has raised a whole lot of questions, especially about PBMs. What questions should you be asking and, more importantly, what answers do you need to keep yourself and your clients safe? We'll find out on this episode of Shift Shapers.
Speaker 2:Change either energizes or paralyzes. The choice is yours. Either energizes or paralyzes, the choice is yours. This is the Shift Shapers podcast bringing the employee benefits industry interviews with individuals and companies who are shaping the industry shifts. And now here's your host, david Saltzman.
Speaker 1:And to help us answer that question, we have invited back Renzo Luzzati, who's president of USRX Care. He last visited us way back on episode 185 on October 23rd 2017. And that's surprising because he's one of my favorite guests and I should have had him on sooner. But he's back and we're glad to have you here, renzo. Thanks for participating.
Speaker 3:It's a pleasure, always a pleasure, david.
Speaker 1:Thank you, sir. So a little bit first about your background for folks who maybe don't remember from the episode a zillion years ago.
Speaker 3:Sure, I've been in and around healthcare for now 30 years. I've done just about everything there is to do. I've worked on the provider side hospitals, physician group practice. I worked for a pharmaceutical company for a number of years. I've worked on the payer side when it comes to pharmacy benefits. I've done just about everything except for prior authorizations. I am not a pharmacist and I've never dispensed a pill Other than that. Everything from the payer side to the benefit side, you name it, I've done it.
Speaker 1:Awesome, and that's why you're able to answer some of these complicated questions. So let's level set. Since we're going to springboard off of that J&J suit, can you give the audience a quick kind of synopsis of what happened and what that action is all about?
Speaker 3:Yes. So, for those that may not be so familiar, there's a set of regulations that were passed in 2021. It's called the Consolidated Appropriations Act and that was an attempt by CMS and the Department of Labor to shift power towards the payers, away from their vendors. I think they realized, and I certainly have seen over the years, that the PBM industry the payer industry has become the club, if you will, the hammer, and taken control away from the plan sponsors in terms of the activity that they can do, in terms of their own spend, in terms of access to information. So the Consolidated Appropriations Act was an attempt to shift the power back to the payer. With that came a focus on fiduciary.
Speaker 3:Plan sponsors are, by definition, fiduciary. It's a term that is defined under ERISA and one of the obligations of employers that have employer-sponsored health plans is that they need to live up to those fiduciary duties and the way that the regulations were structured. Employers have to attest every year that they're meeting that obligation and they are open to potential lawsuits from employees if they are not living up to their fiduciary duty. It's the same practice that was put in place with the 401K industry years ago, and so it's the same playbook now looking at benefits. So J&J happens to be one of the first notable employers that is being sued under that statute and there are a number of attorneys that are out there soliciting cases to take up against employers. So I think this is just the tip of the iceberg. But this was notable in two respects Number one, it's a large company and number two they're a pharmaceutical manufacturer Ultimate irony.
Speaker 1:So what exactly was the complaint, or the main complaint that centered around the pharmacy piece?
Speaker 3:or the main complaint that's centered around the pharmacy piece. Yes, so they used a PBM called Express Grips and in looking at the claims, the amounts that they were paying for pharmaceuticals greatly exceeded the cost, and one could say that the cost was excessive compared to the level of services that are being provided. And there are certainly multiple other options in the marketplace whereby J&J could have acquired those drugs for their members at a lower cost. So that is really the crux of the lawsuit.
Speaker 1:Excess payment. Excessive is kind of an understatement in this case. As I recall, it was an MS drug that you could typically get for somewhere around $80, and the plan was being charged $10,000 for it. That kind of goes a click or three beyond accessible.
Speaker 3:Well, I'd like to say that what plan costs, the PBM calls profit right and you just have to follow the money right. I mean, you know they're kind of cherry picking individual cases. I'm sure there's other cases where the margins were not nearly as high, but we see this fairly frequently, particularly with generic specialty medications that are being dispensed at the specialty pharmacy. The discounts are generally not as good as what you could achieve in a retail pharmacy. So we as an organization, when we take over a group, we always look at the lowest cost option. If the specialty pharmacy is the best price, great. If the retail pharmacy is the best price, we let the member get that medication at the retail pharmacy. Traditionally in the PBM world, the PBM has an exclusive on dispensing specialty medications from their pharmacy, and therein is where some of these disconnects come into play.
Speaker 1:But that's not necessarily an obligation. I mean, the contracts can be structured a number of ways and in some cases they can be structured so that you can get it from any place right.
Speaker 3:Yes, it's really up to the employer and the consultant. The traditional model excuse me, the traditional model is that the contract says that if the specialty pharmacy is owned by the PBM, that the plan sponsor must use that pharmacy, and that is just the typical of what we see in the marketplace.
Speaker 1:So there are some pharmacies. We've talked about fiduciary now a little bit in terms of what the plan does and what the plan sponsors need to do, and I should hesitate to point out that, shouldn't hesitate to point out that the advisor was also named in this paperwork. So there's plenty to go around, but there are some PBMs, such as yours, that say that they're operating in a fiduciary model. What does that mean in general and what does it mean for both the plan and the advisors?
Speaker 3:Yes. So that's a great question. So fiduciary is actually a legal term that is defined under ERISA. It also applies to the financial services industry, but we're talking about the healthcare industry and specifically about PBM services. So ERISA defines a fiduciary with three main components. Number one you can't have any conflicts of interest. Number two you have to look out for the best interests of the plan and plan participants. And number three all utilization and financial information has to be in full view, ie transparency.
Speaker 3:So, being in the PBM industry, there has been a movement in the last several years towards transparent PBMs right, and there's a lot of companies out there that are transparent PBMs. Transparency is one of three elements under fiduciary right. So often I'm asked are you a transparent PBM? And I say we are in that transparency is one out of three tenants. But we don't believe transparency is enough. You could be transparent and conflicted. You could be transparent that you're overcharging by $10,000 on a script. That is not fiduciary compliant because you're not looking out for the best interest of the plan, getting the lowest available cost, and usually those markups come with conflicts of interest. So, from our perspective, when we came into the marketplace, we realized that fiduciary really is where the market needed to go. There are a number of employer organizations that are lobbying Congress to require PBMs to be fiduciary and so far the industry has not been all that favorably inclined to move in that direction. All that favorably inclined to move in that direction.
Speaker 1:And from a practical matter, the industry would need to turn its revenue model upside down in order to be compliant. One of the things that you mentioned that I found really interesting I made a note of it during our discussion before the recording was that you said this particular CAA there are CAAs almost every year, but this particular one was a gift. What did you mean by that?
Speaker 3:Yes, so it was a gift to employers in that the regulation has some elements in it that help them keep, and I'll talk about PBMs, but it also applies to carriers keep the vendor in check. It also applies to carriers Keep the vendor in check. One of the things is no gag clauses, which means that, at the end of the day, the client owns their own data and cannot be restricted from accessing that data this is still a bone of contention were passed in 2021, and we're still encountering employers that are having a difficult time getting their own data from their plan. We're expecting some additional guidance to come out from the Department of Labor and CMS and there potentially could be some lawsuits in and around this arena as well. Access to data arena as well access to data.
Speaker 3:So transparency is part of what is trying to come out of the Consolidated Appropriations Act, and that in and of itself, is a tremendous gift to employers, just to have more visibility in terms of what's going on. But the other thing is you know now they're being held accountable for being fiduciaries and you can't say well, I hired my consultant and therefore I'm compliant. The J&J lawsuit says that that does not shield you from your obligation to be a fiduciary, which means you need to be educated, you need to be asking questions and you need to be monitoring your own plan right and you need to be monitoring your own plan right. So employers just need to step up to the plate. They need to take this regulation that was put in place with them in mind and leverage it to make sure that they are living up to their fiduciary duty and that the vendors that they choose to touch their benefit are also in compliance.
Speaker 1:You mentioned to me again earlier that there is typically 40 to 50 percent overspend on the pharmacy side and you rightly pointed out in our conversation that an employer would never accept that on their manufacturing line or in their line of business. Why has it been so pervasive in the pharmacy universe? Is it just lack of knowledge?
Speaker 3:I think that there is this perception, which is absolutely not correct. But there's a perception out there that healthcare costs cannot be controlled, right, or, if they can be controlled, the goal is to keep it to a 1% or 2% increase a year, as opposed to an 8% to 10% increase a year. The other issue is the way the industry has been structured. I mentioned this before the way the industry is structured. Now talk about the PBM industry. The more that the plan spends on their PBM benefit, the more the PBM makes. It's a direct conflict of interest. The entity that is supposed to be containing cost makes more money when the plan spends. It really should be the opposite. If you think about it, the PBM should be getting paid more if the plan is paying less. Right, that would be an inlined incentive. That's not the way the industry is structured.
Speaker 3:I often say, you know? For individuals that say well, it's very complicated, the PBM industry, it's a black box. They really don't understand it Really. All you need to know is PBMs are in the business of selling drugs to members at a profit. If you understand that, you pretty much understand the industry right. Any which way that the PBM can make an extra nickel on every drug that is dispensed is in their favor right, and from a fiduciary perspective, particularly entities that are publicly traded their fiduciary duty is to their shareholders right, which is not necessarily going to be the same as the end user, the client, the plan sponsor, right. So there's just this inherent conflict in the way that the industry has evolved that has resulted in the outcry of late, particularly as specialty medications come to market and are starting to break the bank in the back of a lot of employers.
Speaker 1:So when I talk to people who are not in the business about this J&J lawsuit, they're answering and I say you know, Johnson, Johnson should have known. Well, okay, they're in the drug business, so maybe you could make that case. But let's take an employer who's got a plan, who's making rubber baby buggy bumpers. How would they have known that that drug was only available? The one I mentioned was only available for as little as 80 bucks, as opposed to the 10,000 that the PBM was charging.
Speaker 3:Yeah, so a couple of ways I'm going to answer that question. First of all, of course, they would not know. They could and should be working with a consultant that has access to the data and could be monitoring so that they. Reality is that the industry is so complicated and the pricing is so complicated, and you've got all of these pockets of profit margin tucked away, many of which an individual employer would never see.
Speaker 3:From our perspective, and I think from the perspective of CMS and the Department of Labor, what they're asking employers to do is to pick vendors that are on their side of the table, that are providing services in a fiduciary compliant manner, as opposed to the tradition, which has been that the vendor has in their contract that they're not a fiduciary and not obligated to act in a fiduciary manner, and everybody signs that contract, which basically means everybody is understanding that the vendor can have conflicts of interest, doesn't have to look out for the best interests of the plan and doesn't have to be transparent, and then, at the end of the year, everyone's upset when all of that comes true. It's in the contract, right? So hire vendors that are in alignment with the fiduciary obligations of the plan and you don't have to worry as much about all the monitoring and keeping track of all this stuff and you overcharge on this and you have a conflict of interest there. You can eliminate that by hiring the right vendor that is committed to living up to fiduciary standards.
Speaker 1:It's interesting in this particular suit that it was brought by an employee and I wonder if that's going to be. You know, once there's one of these lawsuits, they tend to proliferate. Is that going to be, you think, an ongoing thing, where some employees are going to start asking for data and looking at pricing? And again, how does an employer arm themselves other than relying on their advisor, because the advisors still need to be educated about all this stuff.
Speaker 3:Yes, and I feel somewhat sorry for the employers at the same time as they've been given this gift.
Speaker 3:Right, because the goal here is to make sure that employers are living up to their duty and asking the right questions, which means that they probably need to look at alternative sources, potentially for expertise.
Speaker 3:Right, your run-of-the-mill benefits broker may not be sophisticated enough in this arena to do the job correctly, right, so it's probably going to be a boon for the pharmacy benefits consultants as well, but that's not necessarily a bad thing. Right, because they can help in terms of the contract negotiation, getting all the nonsense out of the contracts. They have the systems that can benchmark prices against other entities and the market. Right, and all of that, I think, is going to come into play. But you know, if you're an employer that can't afford to spend millions of dollars on consultants, again, choose your vendors wisely. Right, a vendor that has in their contract a stipulation that they need to dispense everything in their own pharmacies, that they control everything, they do all the prior authorizations, they do all the clinical reviews and you have no control over your plan and they're not a fiduciary and not obligated to act in a fiduciary manner, may not be the best choice to manage all aspects of your pharmacy benefit.
Speaker 1:So let's talk a little bit further about those employers who don't have millions of dollars to throw around. They're going to rely on their advisors to a large extent, and advisors, more and more today, have a choice, because the plug-and-play aspect of self-funded plans has gotten more and more pervasive. And now a word from our sponsor. This episode is sponsored by MZQ Consulting, a concierge compliance firm that excels at making the complex simple. Have you seen the news lately? Johnson Johnson is being sued because J&J's health plans failed to negotiate lower prices for prescription drugs. In the case of one drug, the plan paid $10,000 for a drug that regularly is available for under $80. Not only were the members of the benefits committee named personally, but their benefits advisor was also named in the suit.
Speaker 1:And that, dear listeners, is why you need a top-flight compliance firm. Yes, mzq handles all the usual compliance stuff, from ACA reporting and tracking to RAP documents, 5500s, mental health, nqtl and QTL analysis and a whole lot more, but the heat is being turned up on fiduciaries who don't act like it. In this environment, using an ERISA attorney-led compliance consulting firm is your best strategy, your clients' too, and MZQ Consulting is where you should go. For more information, go to wwwmzqconsultingcom or email them today at engage at mzqconsultingcom. Now back to our conversation. Let's look through the other side of the periscope for a minute. What do advisors need to know in order to ascertain that a pharmacy benefit manager is a good fit for their client and is being living up to all three tenets of being a good fiduciary?
Speaker 3:So one of the things that we've done over the past several years actually, we have disseminated a set of questions that advisors can ask for existing clients as well as, more importantly, for prospecting. Pharmacy benefits is a great avenue for prospecting because it really is the lowest of low-hanging fruit. Changing out medical plans is a little bit more difficult because employers are attached to their doctor, right? Are they in network, out of network? Where in pharmacy pretty much all the pharmacies are in network? It's just about swapping out the management and the philosophy.
Speaker 3:So we do have a set of questions that you can ask and a lot of them point back to the PBM contract. If an advisor can walk out the door from a prospect with a copy of the PBM contract, they're done. You don't have to be a rocket scientist to look for a couple of things in there and you can go back to your prospect and point those out and you're off to the races. If anybody would like to get in touch with me, they're welcome to do that. They can do that through our website and we'll send you a copy of those questions, because they really have been dynamite in terms of opening up that conversation, opening up some eyes and leading employers to ask questions of their consultant and their PBM, which are the right questions vis-a-vis where they need to be in terms of the Consolidated Appropriations Act.
Speaker 1:And we'll put a link to that in the show notes. So if you're interested in getting in touch with Renzo's organization, usrx Care, and finding this set of questions so you can educate yourself, that would be an easy way to go about doing that. So check out the show notes at shiftshapersonlinecom. That'd be great. Where do you see all of this going in the next three, four, five years? I mean this whole notion of people being aware of fiduciary responsibilities. It's old hat, as you pointed out earlier. It's old hat in the retirement side of the business, because that's where ERISA got its chops, that's where it started the Employee Retirement and Income Security Act. Where do you see this going in the short term and then maybe in the middle term?
Speaker 3:Yeah, so it's interesting. So what we've noticed is that small to medium-sized employers have been the ones that have been fastest to move away from the traditional model. I think because the cost and the pain of doing the same old thing over and over just got too high, right. So the platform was on fire and they jumped right. And when they jumped they realized, hey, the water is warm and it's cozy and it's comfortable and this is awesome, and my costs are down 30%, 40%, 50% and my employees' cost is down 30%, 40%, 50% and I don't have a line at my door. This is wonderful. They'll never go back.
Speaker 3:It's the larger employers that are still, to a large extent, buying the same old way, are still, to a large extent, buying the same old way. One of the things that we do that has been a growing market is for large employers that don't want to change their PBM or find it to be onerous to even think about changing their PBM, is they're deconflicting the clinical decision-making by carving out the prior authorization and therapy interchange, moving from higher cost to lower cost options within the formulary. By doing that and the clinical decision-making is a critical cost driver, right, if you get that wrong, you're going to be spending on drugs that are inappropriate, that are to treat the wrong condition, that may have safety issues that are not needed, the wrong condition, that may have safety issues that are not needed. By bringing independence to the clinical decision-making, by removing it from the PBM, that is really the provider. If you think about it, it's not much different than a hospital.
Speaker 3:You know, 30 years ago hospitals lost control of all of the decision-making. For those that are in the patient or are admitted, or they're getting a procedure right You've got to get pre-cert for a $700 MRI, right the hospitals lost the ability to make those decisions to independent third-party medical management firms. It's the same thing that we're seeing on the PBM side. The PBM is dispensing, they're collecting manufacturer's incentives, they're controlling the formula, all is dispensing. They're collecting manufacturer's incentives, they're controlling the formula, all of that. And they're also the gatekeeper right. They're the ones deciding whether that million-dollar drug should be dispensed or not.
Speaker 3:So we're increasingly seeing the larger employers stay with their PBM but move the clinical decision-making to an independent, unbiased third party, of which we provide those services and there are others in the marketplace as well and by doing that they take the conflicts of interest out of the clinical decision-making process, just like occurred 30 years ago with hospitals, when HMOs and medical management firms came into play. So that is a trend that we're definitely seeing and I think we'll see a lot more of that. We're also seeing the larger employers kind of unbundle and use the PBM for claims processing, but all of the other functions are carved out to different entities that have expertise and independence in their area. So that's kind of what we're seeing.
Speaker 1:Because I mean, the way we've been doing this is there are a lot of hands in that same pocket, but not all those hands have actually added any value along the way. They've just added some cost along the way. So if an employer took that approach, would I know you're not a lawyer, you don't dispense legal advice, but would that be an affirmative fence? Would that keep them out of the kind of soup that Johnson Johnson is in or at least give them the ability to say look, we made an effort, we did our best, or do they need to do other things?
Speaker 3:Yeah, I mean again, yes, I'm not an attorney, and that's for sure. But you know, I think just looking at the results kind of speaks for itself, right? And you got the Blues out in California that took this stance for themselves, right, that was, I mean, that sent a shutter wave, shutter wave through the industry. Oh my god, the blues decided that using one entity to do everything wasn't the best approach. So they've carved it up and have saved millions upon millions, upon millions of dollars. So I would say, yes, the one thing that we do here and we're sensitive to this as well but there are times when it's appropriate and times when you don't have to unbundle. But employers, we increasingly hear I can't have one more vendor, I got so many vendors, I can't possibly take on one more, right? So one way to do that is to move the basket to an entity that is aligned with your fiduciary goals contractually in the contract. So now you're dealing with one vendor and you don't have to worry about anything. If that's not an option, then figuring out strategically what areas are the greatest drivers of cost and how can you make sure that you've eliminated the conflicts of interest in those areas will be important.
Speaker 3:Again, on the clinical side. This is healthcare right. If you're not getting the healthcare right, you're off track. So on the medical side, it was decided years ago that there's going to be a case manager assigned to everybody that's in the hospital, and if you want an MRI or if you want an expensive procedure, a brain scan, someone's going to look at it for medical necessity and it's not the hospital, right? That same model on the PBM side makes infinite sense, particularly when you're talking about drugs now that are $100,000, $500,000, $1 million, $2 million, right. Why would you have the entity that profits off of the providing of the service, the dispensing of that medication, make the decision whether it's medically necessary or appropriate or not? It doesn't make any sense. So if you're going to make one change, carve out to another vendor. That's a we think, and employers have now been voting with their feet. We think and employers have now been voting with their feet. They also believe that that's a high-value move without creating disruption or a lot of extra work for HR in terms of the implementation.
Speaker 1:It really operates behind the scenes in many ways and the savings are dramatic. And yet does there need to be a component additionally for employee education? Because nothing I think the technical insurance term is pisses off an employee more than having to pre-auth stuff.
Speaker 3:Yes, you know, being in this business for as long as I have, there's the two hardest jobs are number one, the folks in client services that are on the lines working with the employers to administer and manage the benefit. Number two are the individuals in the prior authorization department. When they're telling an individual that their medication does not meet criteria for coverage right, that's hard. I mean, at the end of the day, good healthcare is good business, right, good medicine is good business. So we, as an organization that does a lot of prior authorizations, pride ourselves at being good clinicians and also following best practices and national standards. We don't see a lot of that, unfortunately, in the PBM industry, in part because it takes a lot of time to do it well and the industry is not incentivized to do it well. As a matter of fact, it's the opposite. If you slow a $2 million drug at getting to the PBM-owned pharmacy to dispense, you're impacting a profit margin, right? So we see approval rates, particularly for specialty drugs, up in the high 90s, whereas a well-managed health plan would be somewhere in the 60s. And what's the difference between 90% and 60%, other than 30% Waste? Complete and utter waste, right, and that's unfortunate.
Speaker 3:So it really does come down to vendor selection, but in terms of the, I want to say one other thing in terms of the member, whether you're working with a fiduciary PBM or a traditional PBM, from a member's perspective, they all look the same. They get a card, they go to the pharmacy, they present the card to the pharmacy, they present their prescription. 90-plus percent of the time they're going to their co-pay and walk out the door, and that's their experience with the PBM. It's the 10% of individuals that are accounting for 60, 70, 80% of the cost that really need the attention. Right, we tend to get to know those folks very well and, at the end of the day, if we're reducing a plan spend by 30 to 50 percent, the members' costs are typically coming down by the same percentages. So think about that. The plan has cut their costs in half and me, as an individual working for my employer, I'm now spending half the amount that I spent last year or the year before on my prescriptions. That's a win-win, and all we did was eliminate waste.
Speaker 1:Members don't see it that way all the time, do they? Members? A lot of times and I'm interested in how you get past this because your operation has been successful, Members see pre-auth or pre-cert or whatever you want to call it, as a bunch of bean counters that are only there to reduce spend, not to help anybody. How do you get past that with a patient?
Speaker 3:So much of the interaction when it comes to prior authorization is with the prescriber. So most of the time the member is really not in the picture. Particularly when you're talking about specialty drugs, you're talking about complex conditions, complex drugs. Trying to have a conversation with a member and relay 30 years of pharmacy practice is tough right. So a lot of those conversations happen with the prescriber. I would say about 5% of the time the member gets involved. So the rational, the decision-making in terms of what's the best for a patient usually will take place between us and the prescriber and then the prescriber communicates to the member what the course of treatment is going to be right and everybody's on the same page. Yes, this is the right thing for that patient.
Speaker 3:Where things get sideways is when the prescriber is not responding. That is the toughest and we call it the stuck patient. Again, we're talking about less than 5% of cases where we're reaching out to the doctor to try to get information. According to the plan, we have to do a prior authorization. We can't just approve a $2 million drug without review. We're reaching out to the doctor, we're calling, we're faxing, we're doing everything except getting on a plane and standing in their lobby to get a response. That's where things get sideways and that's where the rub comes in for the patient more often than not. Usually we can resolve those in a couple days. Sometimes we have to get the patient involved to contact the office to get them to move.
Speaker 3:I would say it's probably you know, I don't know half a percent, 0.2 percent of cases where things bubble up to human resources and to us, where the patient is upset that they can't get the medications that they need.
Speaker 3:But a lot of it has to do with good communications, both with prescribers and members.
Speaker 3:And I've often found, just from my own experience over the years, if you explain to the patient the rationale, sometimes they get upset at their doctor for prescribing whatever it was in the first place, particularly if it was expensive and there's a lower cost option that will do the same thing first place, particularly if it was expensive and there's a lower cost option that will do the same thing. So I agree with you that that is one of the hardest things in this business, but it doesn't have to be and at the end of the day I could tell you countless stories of patients that have been on drugs that they shouldn't have been on because it was for a condition they didn't have or a dose that was too high. And when you right the ship right, you're not only impacting in a positive way cost, but you're also improving quality of care. So that's the other thing I guess I would say with respect to prior authorization the way we do it in a rich, clinically driven manner, not a profit driven incentive manner you tend to end up with better care.
Speaker 1:And that's a great place to end our conversation for today. Renzo Luzzati, president of USRX Care. Renzo, we promise we will have you back sooner than we did last time, because you're always a wealth of information. Thanks for sharing it with our audience.
Speaker 3:David, this has been great, thank you.
Speaker 2:Our pleasure Shout out to the crew at Grand River Agency for their awesome post-production. This Shift Shapers podcast is copyrighted content and may not be reproduced in whole or in part without the express written permission of Shift Shapers Solutions LLC. Copyright 2024.